How often have we witnessed an overly-maudlin proclamation of “Drugs kill”? We envision a wild-eyed war on drugs crusader calling for tougher action, oblivious to the much-needed demise of that devastating and sorry excuse for drug policy. We roll our eyes and change the channel, close the book, click on close, or stop listening. Interestingly, the reality is that drugs do kill people – lots of them. The Canadian Centre on Substance Abuse’s Report, The Cost of Substance Abuse in Canada showed that, in Ontario alone, the toll for alcohol, tobacco, and illegal drugs comes in at about 80,000 deaths per year. The corresponding figure for Canada is about 220,000. These estimates do not include deaths from pharmaceutical products – a noteworthy exclusion. Yet, even these underestimates represent almost one in five of deaths from all causes. Drug-related deaths are a serious problem in Canada. However, the disturbing reality these numbers represent does not, and never did, justify the war on drugs. A sensible response to this level of carnage is not one of harassing, arresting, convicting and imprisoning drug users - essentially oppressing their rights, and in many cases, destroying their lives. But we should not dismiss the data or the concern about drug-related deaths simply because the data have been used to forge delinquent drug policy. The data have their own inherent legitimacy which needs to be repurposed as part of a drug policy strategy based, not upon fear or bigotry, or upon the desired trajectory of one’s political career, but upon principles of social justice and public health.
In the media and in prime time television shows, over many decades, we have been frequently exposed to gruesome deaths related to street drugs such as LSD, heroin, speed, cocaine, crack, and more recently crystal meth and bathsalts. Occasionally, a death from a drunk driver would appear. But the reality of drug-related mortality is quite different. The Canadian Centre on Substance Abuse’s Report, The Cost of Substance Abuse in Canada crafted an important marriage of data on drug mortality with the type of drug involved. In doing so, it provided one of the most important insights ever in the addiction field. It was a game-changer. This report identified tobacco as the major cause of drug-related mortality. Against the prominent backdrop of the war on drugs, that finding surprised a lot of people – even people working in the drug and health care fields. But the much greater surprise for just about everybody was the magnitude of the gulf between the number of tobacco-related deaths and those related to other drugs, including alcohol. Tobacco accounted for a staggering 86.7% of all drug-related deaths in Ontario. Alcohol came in at 9.1% and all illegal drugs combined at 4.2%.This picture is not different from the rest of Canada or from most places in the world.
The data from The Cost of Substance Abuse in Canada was collected in 2002. We have some more recent data from reports published by The Institute for Clinical Evaluative Sciences (ICES) & Public Health Ontario (PHO). These reports do not use the drug categories (“tobacco, alcohol & all illegal”). Using data collected from 2005-7, ICES/PHO show that deaths per year and years of life lost (YLL) are much higher for alcohol than for cocaine & for prescription opioids. This difference remained when YLLs were combined with year-equivalents of reduced functioning (YERF). Finally, using data from 2001-5, it was shown that life expectancy, adjusted for quality of life, was reduced for those who smoked tobacco at unhealthy levels compared to those who drank alcohol at unhealthy levels. So, based upon these more recent data sets, the general picture for mortality in 2002 appears unchanged. Tobacco is still the major threat, followed distantly by alcohol, and then by other drugs.
I would like to share an interesting perspective on the causative mechanism for tobacco-related mortality - a perspective that arises from epidemiology. Any contagion that causes disease is spread by a vector. A greater exposure of a vulnerable population to the vector results in a more widespread epidemic of the disease. For example, the parasitic contagion that causes the disease malaria is spread by the mosquito as the vector. The identification of the vector is always an important step in addressing the spread of a disease. For tobacco-related disease and mortality, the vector is the tobacco industry’s promotion and distribution of its product. The focus of attention on this vector is believed to have played a major role in reducing tobacco use. We need to learn from that success in addressing other drug problems. Those lessons will also serve our initiatives aimed at other lifestyle problems and issues such as unhealthy eating, compulsive gambling and gaming, and violent media.
This post brings us to the homestretch of our reconnaissance of indicators of drug-related harm. Over thirteen posts (plus one more to come), we have sorted through a lot of data, identified strengths and limitations of the data sources, discussed a variety of methodological issues, explored drug use within a broad societal context, told stories, made confessions, challenged convention, courted controversy, and even worked in some Shakespearean and nautical metaphors. I would like to acknowledge the contributions to the discussions that some of you have made along the way. You enriched the experience for everyone, including for myself. In the final post of this series, I will briefly reintroduce and summarize the results of the six indicators and finally offer, for your consideration, an answer to the question that I posed 22 weeks earlier (May 19): What is the worst drug problem?